NYLB - Report Misconduct Form

Form Sections:

Form to Report Fraud/Misconduct

1. Reporter Information
*Section 1 items OPTIONAL. Your name will be kept strictly confidential.*
Last Name, First
Street Address
City/Town•ST•Zip
Email Address
Telephone Number
(It is important to provide a way to contact you.)
2. Type of Misconduct
Please make only one selection per form.
Information concerns:	Insurance Fraud Vendor Employee Other –
3. General Information
If you need more space, please add additional information in section 4.
Who did this
Where did this happen
When did this happen
Who did this happen to
How did you find out
Who else knows about this
4. Detailed Report
Describe exactly what incident you would like us to be aware of. Please be as specific as possible. Include names, dates, times and places. Also let us know who we should talk to in order to get further information or where we might locate evidence.